Science, Medicine, and the Anesthesiologist

It is widely accepted that the evacuation of acute supratentorial intracerebral hemorrhages does not improve patient outcomes. However, recent advances in minimally invasive neurosurgical techniques (such as trans-sulcal parafascicular surgery) enable effective hematoma drainage with less damage to the surrounding brain and thus may produce better functional outcomes. Three hundred adult patients suffering from 30- to 80-ml volume hemorrhages in cortical lobar (69.3%) or anterior basal ganglion (30.7%) brain regions were recruited to an adaptive randomized trial at 37 U.S. centers sponsored by the maker of the surgical evacuator used. Patients received either minimally invasive surgical hematoma removal within 24 h of the hemorrhage (surgical group, n = 150) or conservative medical management alone (control group, n = 150). The primary outcome was a utility-weighted modified Rankin scale at 180 days after the hemorrhage. The surgery group had a better Rankin score (0.458) than the control group (0.374; 95% Bayesian credible interval, 0.005 to 0.163; posterior probability of superiority of surgery = 0.981). The difference in outcome was greater in those with cortical lobar hemorrhages than those involving the basal ganglia. Fewer in the surgery group (n = 14) died by 30 days compared to the control group (n = 27).

Take home message: In this multicenter, randomized, adaptive trial, the use of minimally invasive hematoma evacuation within 24 h of a supratentorial cerebral hemorrhage results in improved long-term outcomes.